MEDICARE: LAKESIDE FOOT AND LEG CARE PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213ES0103X	Foot & Ankle Surgery Podiatrist

General Provider Information

NPI Number	:	1598323909
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKESIDE FOOT AND LEG CARE PLLC

Provider Business Mailing Address
First Line	:	14322 GRANDVIEW DR
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48313-3447
Country	:	US
Telephone Number	:	248-739-1379
Fax Number	:

Provider Business Practice Location Address
First Line	:	14322 GRANDVIEW DR
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48313-3447
Country	:	US
Telephone Number	:	248-739-1379
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SIRAJ PANCHBHAIYA
Credential	:	DPM
Telephone Number	:	248-739-1379

Provider Enumeration Date	:	05/31/2019
Last Update Date	:	01/23/2023

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